Circumcision

There are approximately 30,000 circumcisions performed each year in England.¹ The highest rate of circumcisions in the developed nations is 65.3% in the United States (National Hospital discharge Survey 1999).

Circumcision of males involves removal of the fold of skin which covers the glans penis. Historically it was performed 15,000 years ago in Egypt and may have developed independently amongst different cultures. Columbus discovered that many New World natives were circumcised. Historically cultures have ascribed benefits to circumcision ( including hygiene, rite of passage to manhood, cultural identity and others). However in the last 20 years it has become more controversial and more scrutinised because of the potential risks to the child's well-being. The American Academy of Pediatrics now advocates appropriate counselling and informed choice before circumcision is undertaken.

Most common reason given for circumcision is to fulfil a cultural norm.²
Strict medical reasons for circumcision include:

• Phimosis. This is when the distal prepuce cannot be retracted over the glans penis. In preschool children it is not unusual for there to be thin adhesions to the glans. This physiological phimosis is quite normal. At age 3 years about 10% of boys are unable to retract the foreskin, but by adolescence 99% of boys achieve retraction. Severe phimosis is quite rare in young children and can be demonstrated by bulging of the foreskin during micturition. It should be remembered that circumcision is not the only option and preputioplasty can also be performed (this preserves the prepuce).
  Acquired phimosis occurs because of:
  • Poor hygiene
  • Chronic balanitis
  • Repetitive forceful retraction of foreskin.
  Phimosis does not obstruct the flow of urine but it can lead to infections, paraphimosis and interference with normal sexual activity.
• Paraphimosis is the inability to pull the foreskin from the retracted state back over the foreskin. It ia a urological emergency which can lead to ischaemia of the glans if left untreated. This can arise for example after retraction of the foreskin for catheterisation. If it cannot be reduced a dorsal incision may be required followed by circumcision electively.
• Recurrent balanitis. Balanitis is infection of the prepuce (posthitis is infection of the glans). Balanitis and posthitis respond to antibiotics and warm baths. Both may be caused by poor hygiene.
• Balanitis xerotica obliterans.

Circumcision has other suggested benefits and indications:

• Recurrent UTI.³ Circumcision is associated with a significantly reduced risk of UTI (Odds Ratio = 0.13); but the benefit of circumcision only outweighs the risk in boys who have either had recurrent UTI's, or are at high risk of UTI (eg high grade vesicoureteric reflux (≥grade 3). ^4,5 Although the relative risk of a UTI in the uncircumcised male infant is 4 to 20 times higher as compared to circumcised male infants, the absolute risk is low (less than 1%). Hence recommending circumcision in all newborn infants on these grounds is not sustainable.
• Prevention of penile cancer. This rarely occurs in circumcised men but in countries where there is a high level of personal hygiene the condition is also rare.⁶ Human papilloma virus (HPV) genotypes 16,18, 31 and 33 are responsible for the great majority of cervical,vulval, vaginal, anal and penile cancers. Circumcision is claimed to reduce the risk of HPV infection in men. Yet again however the low absolute risk means that there is not an argument for universal circumcision.
• Reduction in the risk of sexually transmitted disease (particularly ulcerative diseases like syphilis). This is as yet unproven.⁷ A meta-analysis of 27 studies does apparently show reduction in risk of STD transmission associated with circumcision.⁸ However other studies show the opposite. Sexual practices of circumcised men may differ from those who are uncircumcised related to their religion.

Assessment should:

• Estimate how much foreskin should be removed.
• Exclude hypospadias, epispadias, chordee and other relevant conditions.

In phimosis circumcision may be avoided by daily cleaning (without forceful retraction) when this is uncomplicated (no urinary obstruction, pain). Topical steroid may be used to separate adhesions between foreskin and glands (applied for 4 weeks daily).

This should be performed by an experienced person using the correct, sterile equipment in an aseptic environment. The penis should be anaesthetised with either a nerve block (either local or regional anaesthesia) or anaesthetic cream.⁹ General anaesthesia can also be used in adults particularly.The patient should be given analgesics afterwards (paracetamol or ibuprofen usually, or with adults oral narcotics). Full recovery requires 4-6 weeks of complete sexual abstinence with loose fitting briefs and instructions to shower and gently wash around the incision site.
In infants various devices are used. The Gomco clamp and the Mogen clamp are useful in infants but not toddlers (increased risk of bleeding). The Plastibell technique can be used in toddlers up to 10kg.

Small penis, buried penis, hypospadias, chordee (ventral penile curvature) without hypospadias, deformity of dorsal hood, penile webbing, epispadias, ambiguous genitalia, bleeding diatheses (relative contraindication).

Minor complications include:

• Haemorrhage
• Local infection
• Meatal stenosis
• Secondary phimosis (especially in babies with a hernia or large hydrocoele)
• Adhesions or skin bridge joining penile shaft and glans.

More severe complications include:

• Septicaemia
• Removal of end of penis
• Removal of too much foreskin
• Urethrocutaneous fistula.